Deep Report on Hypertension

Hi Mart,

Thanks for your interest! You would have seen the discussion of potassium in the section on potential interventions - and I think the TLDR is that it does look good, but does cost money. Hence, we're pursuing sodium reduction right now; but as we work with our partners doing the actual advocacy reach-out to governments, we'll definitely get them to raise potassium as an option. Hopefully, in the long term, economies of scale make these more cost-competitive.

Wow thanks I didn't know about the potassium alternative ( and in as doctor), that's exciting I might look into it for myself!

Would not be a difficult cost effectiveness analysis to see if this made sense, nice idea.

I just realized that I could also just follow the links and found a part of the answer

[...] Another expert is more bearish, noting that though a Chinese RCT does show positive results, and the current evidence is convincing, still more studies are needed, with the magnitude of benefit not as large as you would think. That said, because it's a substitution of sodium for potassium, there's a double benefit for cardiovascular health; people don't consume enough potassium, and potassium lowers blood pressure. And while there is a concern that increasing potassium intake across the population can create risk to people with chronic kidney disease, the evidence is that such people tend to suffer from cardiovascular disease anyway – most hypertension sufferers have higher risk of diabetes/obesity etc.

in section 4.1 1) g)

and also

Of huge interest too is potassium substitution; though evidence of that is fairly new, they think it is a game changer that can accelerate action. They are trying to figure out the name (e.g. potassium-enriched salts) from a public relations perspective. Increasing potassium reduces heart disease – it is an effective strategy. Low sodium salts in general do cost more – perhaps double the price. Then again, Himalayan salts are similarly twice as expensive, yet people still buy it – the challenge is getting the message out there, and that it is good for you (i.e. benefits of potassium); in Australia they are trying to understand the barriers to scaling up. There is research on how to get potash in a scalable way – there is a lot of potassium out there, and only a small amount is food grade (20%), with the rest (80%) used for things like fertilizer.

in section 3.3. Global Salt NGO, point 2.

I am happy to learn that people are working on this :) And it does make sense that the increased price also creates difficulties for adoption. This certainly isn't a trivial problem. Also, I agree that the public relations perspective is important. Here in Germany, there were large health problems due to missing Iodine, which were reduced by fortifying table salt - but even though the necessity for Iodine hasn't changed, people/products are starting to use the fortified salt less.

Yep, and that's about 5x existing GiveWell top charities. Also, GiveWell has made a 700k grant to Resolve to Save Lives (RTSL) for their salt reduction work in China; CEARCH previously recommended and evaluated RTSL for their salt policy work in Southeast & South Asia, and I'm very excited to see GiveWell make this exploratory grant.

Thanks, Denis!

I think the main takeaway for other cause areas would probably just be how impactful changing government policy is - you trade off (a) needing to persuade governments in the first place, for (b) massive scale of impact and also (c) much, much lower counterfactual cost of government expenditure relative to EA expenditure. There's a lot of stuff that may not be worth doing if the price was less money to GiveWell; but not if the price was the US government running a slightly higher budget deficit.

Hi Vasco,

We have standard GCR discounts when estimating long term impact, but for AI - we're generally more sceptical, both on paperclipping and on extremely rosy projections of economic growth. In any case, while there might be a theoretical case for discounting income-based interventions (if you really believe GDP growth is going jump to 10% per annum, we're obviously moving up the DMR curve more rapidly), there's much less direct impact on health (in fact, if you think income is going to drastically increase, that makes consumption greater, and the DALY burden of diseases of affluence much worse, and hence preventing them more cost-effective).

Definitely - though I think mandatory reformulation is the best amongst the existing top solutions we recommend. It shows the largest effect size under the modelled parameters, but also it's probably less politically toxic - taxes are comparatively harder. We see this with climate too, where people favour quotas/quantitative limits over taxes even if the effects are literally identical.

Hi Vasco,

(1)   In hypertension/salt reduction policy, CEARCH (in collaboration with the donors we advise) has made 150k in grants (specifically, projects advocating for - and assisting governments in implementing - reformulation policies to reduce sodium in food).

In diabetes/soda taxes, CEARCH has made 63k in grants (specifically, technical assistance to improve enforcement of and compliance with SSB taxes).

(2)   For the the bigger GW grantmakers, I'm unsure how much I can share given confidentiality, and I don't want to falsely give the impression that these grantmakers have already developed any specific views/positions/recommendations in this area, but I think I can broadly share that:

(a) FP previously asked us to help evaluate two large global NGO that worked on salt policy, with a specific focus on trying estimate the counterfactual advocacy success rate of salt policy advocacy campaigns (it's about 10%). We ended up making a positive recommendation, particularly for RTSL and its salt reduction work. Note that FP already supports RTSL's trans fat reduction work.

(b) GiveWell is currently considering making a salt grant to RTSL, but I understand it's exploratory in nature (see how this goes, then follow-up from there). They have also done some internal CEAs of SSB taxation projects; I think their major concern (a frustration shared by us) relates to high uncertainty over the existing GBD estimates of the SSB burden (n.b. the estimates changed wildly from one iteration of the GBD to the next, and it's not clear to us how or why the methodology changed). FWIW, I don't see any evidence that the GBD estimates are systematically biased (particularly upwards, which would be the main concern), so we're happy to go ahead.

(3)   Broadly speaking, I'll say that while there is very good reason think that health policy to prevent NCDs is extremely cost-effective (NCDs are a big and growing problem + policy offers large scale of impact at low cost), it's also very risky, and very much hits-based EV-maximizing grantmaking, which is not something many grantmakers or donors are comfortable with. Correspondingly, we've only been able to move about 100k per annum so far in this area (compared to something like mental health, where we helped a partner move 10x that).